Monthly Archives: May 2017

The former ONC chief thinks consumerism will play a major role in promoting data exchange.

Interoperability doesn’t just mean ensuring easy data exchange between two EHR systems anymore, Karen DeSalvo, MD, said on Tuesday. Patients have have an essential role to play, too.

DeSalvo, former assistant secretary for health and national coordinator for health IT, spoke at the Bipartisan Policy Center in a panel discussion with Andrew von Eschenbach, MD, former Commissioner of the U.S. Food and Drug Administration.

The discussion, moderated by former U.S. Senate Majority Leader Bill Frist, MD, was about “Patient Safety and Information Technology,” and it aimed to explore ways IT can still do better at enabling improvements to help prevent medical errors, which still cause the deaths of more than 200,000 Americans each year.

There are myriad ways health IT can help prevent adverse events, DeSalvo said, whether it’s the ability to check for drug interactions in an automated fashion rather than having to thumb through a hefty formulary with very thin pages, or advanced clinical decision support, which has shown that it can improve the safety of care.

We’ve come a long way since 2009, where the passage of the HITECH Act and subsequent federal investment of $36 billion laid the groundwork for a nationwide health information technology infrastructure, she said.

“The iPhone was barely on the market back then,” said DeSalvo. “We were barely thinking of IT in the way we do today.”

Flash forward eight years, and 90 percent of providers are up and running on EHRs.

“Many people have multiple electronic health records,” said DeSalvo. “We have a nice opportunity to leverage that data and make it more actionable.”

Culture change required for interoperability

But for all the progress the past decade, “IT is still in an adolescent phase,” she said. It can be clunky and there are challenges with usability, too. “There’s a lot of hunting and pecking still going on,” said DeSalvo, and plenty of work to do simplifying systems to reduce the signal-to-noise ratio for overburdened clinicians.

And interoperability, of course, remains a challenge.

“We’re increasingly using shared standards, but not quite there,” said DeSalvo. The flow of data is complicated too by “another suite of technologies that are unregulated because they’re about lifestyle and management,” and sometimes by providers’ misunderstanding of HIPAA, “which is meant to guide sharing, not prevent it,” she said.

One essential challenge to more widespread interoperability is cultural, said von Eschenbach. Physicians of his generation “grew up in a culture that was highly egocentric and individualistic.

“I was brought up to play golf, he said. “Today the game is basketball. We have to come together and work together in a more collaborative and interoperable way.”

DeSalvo agreed that quality improvement and value-based care depend on that collaboration.

“I don’t think you can get there without a team-based culture,” she said. “I still believe that moving to value-based payment is a driver to get more doctors to think about cooperation. Better data does change culture and behavior.”

But one key factor to changing attitudes about interoperability is often underappreciated, said DeSalvo: The role of the patient.

More widespread use of APIs has opened up opportunities for a lot of innovation, particularly with regard to consumer-mediated exchange, she said.

Giving patients more control over their health data “creates a completely different window to their health world,” said DeSalvo. “It doesn’t have to be two systems talking to each other.”

Increasingly, she sees data flowing toward places where consumers control, manage and share their data, enabled by trusted third parties and digital vaults.

“People have a willingness to free that data, so it can be put to good use,” said DeSalvo. “We are a team, and part of that team is the consumer.”

The model of healthcare is fast-evolving to make this more and more prevalent, as patients have more skin in the game with higher out-of-pocket costs, she said. They’ll have more agency to choose their providers based on the services they can provide, and “more and more they’re going to want to have access to their information.”

The use of electronic health data for quality measurement and improvement in healthcare has not yet realized its full potential, a problem that must be addressed if the industry is to successfully transition from fee-for-service to value-based payment.

That’s the consensus among industry stakeholders who participated in a roundtable discussion hosted last week by the Office of the National Coordinator for Health Information Technology.

“We are at a critical point in how we think about quality measurements and how we think about quality improvement in general,” Robert Anthony, senior policy advisor in ONC’s Office of Clinical Quality and Safety, told the gathered group of subject matter experts.

Quality measures are vital as the industry moves from fee-for-service to value-based payment. According to consulting firm Discern Health, as much as 80 percent of U.S. healthcare spending will be linked to quality measures or value-based payment models by 2020.

“We’re in a world where it’s not just about reporting any result, it’s about reporting your optimal result—and, payment is tied to it,” said David Kendrick, MD, chair of the Department of Medical Informatics at the University of Oklahoma’s School of Community Medicine. “We’re seeing the level of emotion about measurement go through the roof among providers, and that means they’re starting to really care about all those terminology issues and the issues in their EHRs.”

David Kendrick, MD

Despite the widespread adoption of EHRs, the mere fact that providers are using the systems does not automatically translate into improved quality of care. In addition, although health IT has the potential to greatly improve the quality of care, the evidence that HIT improves health outcomes is still relatively limited.

To help address the problem, Kendrick argued that measures must be standardized, replicable, validated, timely, as well as actionable.

“Medicare and most payers are betting the farm on measurement right now, and I’m very worried about our infrastructure to support that,” he added. “Claims data is a mile wide but only an inch deep. So, it has the unique benefit of encompassing most of what’s happened with the patient, but it doesn’t have the deep clinical variables in it (that) we would like to have, and it’s certainly not timely enough for most measurement that we would want to do for actual quality improvement.”

On the other hand, Kendrick said electronic health record data is “a mile deep, because it has all of that clinical information in it, but it’s only an inch wide.”

While EHRs “may be considered the core for data for eMeasurement, it’s really important—and I would even say essential—to integrate with other types of data in order to truly capture what’s happening at the patient level and being able to capture what happens across multiple providers and systems,” said Sarah Sampsel, vice president at Discern Health. “To improve quality of care, not just the quality of life for that person, we have to be able to capture more than what’s in an EHR.”

Speaking figuratively, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, said “it’s criminal that providers don’t have access to all their claims data—they only get it for the risk patients, if they happen to have a risk contract, but they don’t get it for everyone else.”

Another challenge cited by Kendrick is that “real patients’ care is scattered across a number of locations,” and “to do measurement appropriately, we really need to have all of this (data) so that we have the most complete picture on each patient that we’re measuring.”

Likewise, Tripathi lamented the fact that healthcare is fragmented and, as a result, so is the electronic health data.

“If you look at the distribution of patient visits across the country, 68 percent of patient visits happen in small physician practices,” said Tripathi. “When we think about quality measurement, we tend to focus on the Mayo Clinic and Intermountain Healthcare. But most of the action and therefore most of the data is in smaller settings.”

Healthcare organizations and health IT developers have cemented their commitment to achieving true interoperability through multi-stakeholder initiatives in 2017.

Healthcare interoperability has been a priority for vendors and providers since the advent of health data exchange.

Timely access to accurate health information regardless of health IT system or location improves provider communication and patient care delivery across the care continuum.

This year, healthcare organizations, health IT developers, and federal agencies alike have made a concerted effort to push the industry closer to its goal of true interoperability.

The following are four recent initiatives and forthcoming projects aimed at transforming interoperability in healthcare in 2017.

New Center for Medical Interoperability opens in Nashville, TN

Last month, several healthcare organizations including Ascension Health, Cedars-Sinai Health System, and Hospital Corporation of America joined forces to open the new Center for Medical Interoperability headquarters in Nashville, TN.

The new facility offers researchers and developers the resources to develop software and devices meeting the latest health IT industry standards.

“The opening of the headquarters and launch of the lab are enormous steps toward addressing the
difficulties that health systems share in getting medical devices and electronic health records to ‘talk’
to each other,” said Center for Medical Interoperability Board Chair Mike Schatzlein, MD.

In an increasingly data-driven healthcare environment, equipping researchers with the tools and facilities to advance accessible, open, and efficient health information exchange is imperative to achieving lofty interoperability goals.

“Enabling this type of seamless communication is crucial to improving patient safety and reducing clinician burnout,” said Schatzlein.

The center maintains a vendor-neutral stance in their development of new technologies.

HL7 and HSPC collaborative set to debut first joint project in June

Health Level Seven International (HL7) and Healthcare Services Platform Consortium (HSPC) recently teamed up to develop industry standards in the name of health data exchange interoperability.

Through the agreement, HL7 and HSPC have been working to develop FHIR standards to streamline exchange between EHR systems.

Specifically, the collaboration focuses on advancing standardized representation of health data through HL7 Clinical Information Modeling Initiative (CIMI) Work Group models designed to work within FHIR profiles.

“HL7 has a long history of formally collaborating with healthcare industry groups such as HSPC to advance interoperability through the adoption and implementation of standards,” said HL7 Chief Executive Officer Charles Jaffe, MD, PhD.

The initiative will also launch joint projects focused on involving clinicians in the validation of clinical data representations and standards to promote coordination of care.

“We are delighted to work with HSPC to develop detailed FHIR profiles based on our CIMI models. Together we are engaging the clinical specialty communities to develop a common set of FHIR-based solutions to simplify workflows, effectively allowing clinicians to provide better patient care,” Jaffe continued.

The team’s first joint project will take place at the Clinical Information Interchange Collaborative meeting this June.

The patient matching innovation challenge will invite developers to design new patient identification algorithms and increase the transparency, standardization, and methods of patient matching.

“From an interoperability perspective, the ability to complete patient matching efficiently, accurately, and at scale has long been identified as a key element of the nation’s health IT infrastructure,” wrote Director of Standards and Technology at ONC Steve Posnack, MS.

Providers receiving data from disparate systems need a way to determine which patient incoming information belongs to with maximum accuracy.

“Patient matching is almost universally needed to enable the interoperability of health data for all kinds of purposes. Patient matching also requires careful consideration with respect to its effect on patient safety and administrative costs,” Posnack said.

Top developers will have a shot at six cash prizes amounting to $75,000.

Patient matching algorithms will be evaluated based on fewest amount of mismatched patients, or best precision, and fewest amount of missed matches, or best recall.

The major prize category will award 3 cash prizes to the teams with the highest F-score based on a combined evaluation of precision and recall.

PCHAlliance and IHE continue work on conformity testing and certification

In February, The Personal Connected Health Alliance (PCHAlliance) joined forces with the Integrating the Healthcare Enterprise (IHE) initiative to develop an entirely new project aimed at improving and simplifying interoperability.

Since then, the duo has worked to improve health data exchange through conformity testing and certification.

“PCHAlliance and IHE share the same vision. That is, we believe that health information exchange is possible throughout the worldwide healthcare ecosystem and, together, we can support new innovations and create solutions to improve health outcomes, enhance understanding and help make big data possible,” said PCHAlliance VP Michael Kirwan. “We are looking forward to expanding our collaboration and working closely to further extend interoperability in healthcare.”

IHE Profiles and PCHAlliance Continua Design Guildelines, which are both standards-based, open specifications, function as the foundation for the joint effort to ensure data collected by providers or patients can enter EHRs without any format or code alterations.

The team’s three-pronged approach involves using IHE Profiles and Continua Design Guidelines to allow the organizations to collaborate on conformity testing and certification.

The organizations then use the resulting aligned tools and processes to offer communication, education, and interoperability demonstrations for providers, vendors, and standards bodies.

May 04, 2017 – With so much planned in 2017 to promote new innovations aimed at improving interoperability, the once-distant goal of nationwide seamless data exchange is a few steps closer to becoming a reality.

A panel of three leaders in the health IT space, including outspoken athenahealth CEO Jonathan Bush, discussed the current interoperability landscape and what new strategies will help shape the future of healthcare connectivity.

Bush was joined in the keynote panel—part of this year’s World Health Care Congress, held at the Marriott Wardman Park Hotel in Washington, D.C.—by Steven J. Corwin, M.D., president and CEO of NewYork-Presbyterian (NYP, New York City) and Craig Samitt, M.D., executive vice president and chief clinical officer, Anthem, Inc. The session was moderated by Dan Diamond, health policy reporter at Politico.

When asked about what the industry is doing well and where they are failing, Drs. Corwin and Samitt had rather pessimistic tones, with Corwin noting that the current electronic health records (EHRs) at NYP, which actually only account for some 40 percent of the organization’s data, are fragmented and not interoperable. “The promise of interoperability is something that has been over-promised,” Corwin said. “The idea was that that various EHRs could be perfectly compatible, but that has not been [the case]. For us, it gets down to having a single EHR, taking [out] the expense of putting them together over a multi-layered system, and then reducing the number of exchanges and linkages we need to have. At this point, our linkage exchange looks like spaghetti wires,” adding that in NYP’s interface engine there are currently 6,000 interfaces, though the goal is to cut that number down to 3,000. “We just can’t toggle back and forth between systems,” he said.

Similarly, Samitt noted that the issue isn’t a technology one, but rather one of willingness and incentives. The Anthem senior executive said he is “highly critical of our industry since other industries have figured it out.” He added, “When there’s a will, there’s a way. I think there is a way for interoperability but less of a will. Information should be a common good as it relates to population health and better care at a lower cost, but we do not treat it that way.” He went on to talk about data ownership, noting, “Payers probably have the most complete data set but it’s not timely. Doctors have the most acute data but it’s not complete. And patients have most relevant data, but it’s not actionable.”

The panelists were then asked who’s to blame for these data sharing issues, a question that usually elicits varying responses from those pointing fingers at vendors to others assigning fault to providers and policymakers. From the payer perspective, Samitt said that claims information is only a subset of the data, and that it’s challenging to get providers to share data, though he also admitted that payers are not so willing themselves. “None of us should own the information; it should be a common good. Let’s keep the information safe and pool it so we can have a true longitudinal patient record,” Samitt said.

From the vendor vantage point, Bush—who two years ago famously tweeted at Judy Faulkner, CEO and founder of Epic Systems, that he would pay the user fee for Epic if the giant EHR vendor would join the CommonWell Health Alliance, an interoperability initiative of which athenahealth is a part of—agreed that the incentives to share healthcare data are not rewarding enough for stakeholders. “For my entire career, no one has wanted to exchange information,” Bush said. “The government has made it largely illegal for providers to get paid by digitally flowing information upstream. And [the feds] do not let just any provider see Medicare data,” adding that his company went through the laborious process of filling out applications and hiring lawyers so that they could get access to this CMS (Centers for Medicare & Medicaid Services) data, only to get denied. “Historically,” Bush said, “Hospitals have said that they are the only place that data can flow so that they keep referral volume and preserve their institution.”

However, things are beginning to change, Bush continued, noting dedication from new Health and Human Services Secretary Tom Price, M.D. to reverse things. “We are [seeing] a willingness on the part of forward-thinking healthcare systems to win by being open. Last year, the 21st Century Cures Act [was passed] and that makes it illegal to block data,” he said.

Bush also called out Epic, Cerner and Meditech, which he refers to as “pre-Internet companies” for now being more open to interconnectivity, proving that there are signs of change in regards to stakeholders’ willingness. “Payers are also giving us claims data they didn’t use to give us, and that gives us information on patients that we can pull together that we weren’t able to before,” he said.

Chiming in on the topic of data blocking, Corwin said that hospitals hoarding data is a fair criticism. “People believe that data can be monetized in healthcare, and that’s particularly true with well-curated genetic information,” he said. “I’m less enamored with that idea; I think that the data [belongs] to the patients, not to the providers. But there are those [providers] out there who do think there’s a market advantage. I’m a big believer in not monetizing data unless it improves patient outcomes,” he said.

Bush further said that athenahealth is building a master patient index (MPI) and also a calendar product that would help doctors on athenaNet get more patient appointments. He referred to EDI and HL7 as standards that will “die since they are pre-Internet.” Bush said it was these outdated companies that advocated as part of HITECH (the Health Information Technology for Economic and Clinical Health Act) to eliminate interoperability as a requirement for meaningful use.

He continued, saying these pre-Internet companies “claim to be interoperable but never will be. They need to go,” he attested. Bush added, “Cloud companies can easily be interoperable. HITECH got everyone onto systems that they’re now stuck with, and the Internet was shut out of HITECH. You have 60 medical specialties and [the idea is that] any EHR will be the right one for all 60? That is absurd. How many apps on your iPhone were written by Apple? Four of them. So [we won’t reach] interoperability until we get rid of these servers.”

Bush went on, “That means we need to invite our competition onto the platforms and be like [Jeff] Bezos [founder of Amazon]. “We must accommodate a new generation and we have to move to the Internet in healthcare. This cannot be a questionable proposition in healthcare in 2017. The new cloud-based EHR companies are coming onto our platform; the nightmare Steven [Corwin] is experiencing connecting different old systems is becoming a thing of the past, slowly.”

Samitt agreed with Bush on how the future might look, arguing that it’s not going to be about EHR-to-EHR connectivity going forward, but rather capturing data elements in the cloud to manage population health. “EHRs connecting won’t be as relevant in the future,” he said. “Data inputted is less crucial than data outputted. So the pooling of information and the analytics will be crucial, not which EHR you are on,” he said.

To close the discussion, the panelists were asked about when healthcare connectedness will no longer be an issue. Bush estimated it would take some five years. On the other end of the spectrum, Corwin predicted that interoperability will be superseded by disruptors such as telehealth, artificial intelligence and machine learning. “Interoperability won’t be solved in the short-run. Patients will demand their own data. And connecting people via regional HIEs won’t happen. I’m very pessimistic about the [prospects] of true interoperability. Samitt was more optimistic, predicting that real interoperability can be achieved in 10 years. He noted that much of it comes down to payment reform as well, pointing out that nearly 60 percent of Anthem’s payments are now tied to value. “Connectivity is not just data connectivity, but we also need to achieve alignment with the patient at the center,” he said.

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The Center for Medical Interoperability is a 501(c)(3) cooperative research and development lab founded by health systems to simplify and advance data sharing among medical technologies and systems. We provide a centralized, vendor-neutral approach to performing technical work that enables person-centered care, testing and certifying devices and systems, and promoting the adoption of scalable solutions.

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